- Life in the Backrooms of Medicine. - Proceedings of the IVth European Congress of Psychology. - Tools for Measuring Behaviour in the Operating Theatre. - Development and Evaluation of the NOTSS Behaviour Rating System for Intraoperative. - In 2002, a number of surgeons in Scotland were intrigued by the development of the ANTS (Anaesthetists’ Non-Technical Skills) system and the use of behaviour rating checklists in other industries such as nuclear power and civil aviation.. - There was a realization in the healthcare and medical literature that adverse events occurred in the operating theatre. - Surgeons and their patients have also had to come to terms with the uncovering and analysis of the true nature and extent of surgical misadventure and failure. - Ten years ago, it was not generally realized that a significant number of surgical patients were harmed not as a result of underlying illness or disease but as a result of their treatment (Vincent et al. - Further analysis of this problem revealed that non-technical aspects of performance play a contributory role in the multifaceted nature of surgical adverse events. - failures in decision-making, teamwork, coordination and leadership have all emerged from case reviews and studies of behaviour in the operating theatre (Gawande et al.. - 2003, Studdert et al. - 2006, Christian et al. - Non-technical skills are defined as the critical cognitive and interpersonal skills that complement surgeons’ technical ability (Yule et al. - Despite the fact that the behavioural (Baldwin et al.. - 1999) and cognitive demands of surgery have been recognized as a critical part of surgical performance (Hall et al. - 2002, Jacklin et al. - 2008), and that effective leadership has been shown to improve team performance (Edmondson 2003), non-technical skills are often referred to as ‘non-operative’ and deemed not as important as clinical science in the surgical literature. - Scant attention has been paid to the cognitive and social processes that underpin intra-operative performance in training as well: training and assessment in these skills are only conducted in a rather tacit and discretionary basis, and the surgical curriculum in the UK does not yet extend to non-technical skills.. - Changes to the configuration of surgical training and education are currently underway in the UK to attempt to streamline development of doctors and ensure that they are skilled at communicating and working as effective members of a team. - This approach recommends that progress through and completion of surgical training be based on competence. - it has moved the emphasis of assessment away from set-piece examinations of knowledge towards learning and assessment of skills in the workplace (see Pitts and Rowley, Chapter 3 of this volume). - Selection of trainees into surgical specialties has also been radically altered and provides an opportunity to formalize the role of non-technical skills in surgical education and assessment.. - The main methods of workplace-based assessment of surgical trainees in the UK are observational tools which cover skills such as ability to work in a multi-professional team (Mini-PAT: Peer Assessment Tool) and communication (Mini-CEX: Clinical Evaluation Exercise). - However PBAs, which are written for specific index procedures, sometimes integrate non-technical aspects (see in this volume Chapter 3 by Pitts and Rowley, Chapter 4 by Marriott et al.).. - The cognitive and social skills which underpin clinical and technical proficiency are recognized as requirements for surgical competency and rank highly as core competencies within organizations such as CanMeds (Frank 2005), the General Medical Council (GMC 2001), and the Royal Colleges of Surgeons in the UK (Youngson 2000, Giddings and Williamson 2007) but until recently there were no tools to reliably assess these skills in the workplace. - This chapter outlines the development and evaluation of the NOTSS system. - Development and Evaluation of the NOTSS Behaviour Rating System 9. - The research drew on previous work in Scotland on surgical competence, professionalism and the skills surgeons required to operate safely and followed on from a similar project which developed a behaviour rating system for anaesthetists – the ANTS system (Fletcher et al. - The aim of the NOTSS project was to develop and test an educational system for assessment and training based on observed skills in the intra-operative phase of surgery. - It was considered important to recognize and understand the unique aspects of non-technical skills in surgery, and not to assume that those non-technical skills identified for pilots, nuclear power controllers or anaesthetists would be exactly mirrored in, or be relevant to, surgery. - The NOTSS system is in surgical language for suitably trained surgeons to observe, rate and provide feedback on non-technical skills in a structured manner. - The phases relate to the three objectives set by the NOTSS steering group in 2003: to identify the relevant non-technical skills required by surgeons, to develop a system to allow surgeons to rate these skills, and to test the system for reliability and usability. - A fourth phase was added to cover a trial in the operating theatre using NOTSS to debrief surgical trainees over the course of an attachment (see Figure 2.1).. - intra-operative non-technical skills, as follows:. - Literature review on surgeons’ non-technical skills (Yule et al. - Survey of theatre personnel attitudes to teamwork, error and safety (Flin et al. - Critical incident interviews with subject matter experts (Yule et al.. - These methods were supported by field notes taken during observation sessions in the operating theatre during operative surgery and a review of surgical adverse event and mortality reports.. - Literature Review. - The aims of the literature review (Yule et al. - 2006a) were to examine the surgical and psychological literature on surgeons’ intra-operative non-technical skills in order to (i) identify the non-technical skills required by surgeons in the operating theatre, and (ii) assess the behavioural marker systems that have been developed for rating surgeons’ non-technical skills. - Within these, the review highlighted the main non-technical skill categories to be: anticipation, decision-making, teamworking, leadership and communication. - At the time of the review (August 2005), there were three research tools in the literature which could be used to measure surgeons’ non-technical skills. - On closer examination, these existing frameworks were found to be deficient either in terms of their psychometric Figure 2.1 Developing the nOTSS system. - Phase 2: Design and development (Yule et al., 2006b) Iterative development (n=4 panels of consultant surgeons) Write and agree behaviour markers (n=16 consultant surgeons). - Phase 4: Debriefing on non-technical skills (in progress) Phase 3: System evaluation (Yule et al., 2008a, 2008b) Reliability (standardized scenarios, n=44 consultant surgeons). - Usability: 2 studies, n=27 surgeon-trainee dyads in total Phase 1: Task analysis (Yule et al., 2006a. - Flin et al., 2006a) Literature review, cognitive interviews (n=27), attitude survey, Adverse. - Developing the NOTSS system. - Development and Evaluation of the NOTSS Behaviour Rating System 11 properties or suitability for assessing individual surgeons rather than a surgical team in theatre. - On the basis of this review, we concluded that further research was required to develop a taxonomy of individual surgeons’ non-technical skills for training and feedback.. - The literature review highlighted the lack of basic data on cognitive and social skills in surgeons, and little was known about prevailing attitudes to teamwork and safety in the operating theatre. - There were no such data available in Scotland, so as part of our initial task analysis, we ran a baseline survey (Flin et al. - 2006a) using a version of the Operating Room Management Attitudes Questionnaire (ORMAQ), initially developed by Helmreich et al.. - At the time (late 2005), it was the most extensively used attitudes questionnaire with operating theatre personnel with data collected from Israel, USA, Germany, Switzerland and Italy (Helmreich and Schaefer 1994, Helmreich and Davies 1996, Sexton et al. - Consultant surgeons had more positive views on the quality of surgical leadership and communication in theatre than trainees and theatre nurses. - These results were taken into consideration in the design of the NOTSS system.. - To provide context and meaning for the literature review and interviews, a psychology researcher conducted observations of surgical cases. - The observer also shadowed surgeons in the perioperative environment to understand how this stage impacted on operative performance. - During this phase of the project, detailed field notes revealed that surgeons displayed a range of non-technical skills, communication was variable and there often seemed to be conflicting priorities between training and service delivery. - There was no standard method of conducting a given operation, the atmosphere or climate in the operating theatre would change depending on which surgeon was operating that day, and the number of people in the operating theatre ranged from four to eighteen. - Often operations would start without critical team members in the operating theatre and without all the information being present. - Distractions seemed to be commonplace and normal;. - on several occasions the operating surgeon had to answer questions about another ongoing operation or speak to someone on the telephone while in the middle of what appeared to be a complex part of the operation for which he or she was scrubbed. - Surgical colleagues indicated that data were not usually collected on non-technical skills, so this would be a short task. - In the end, we reviewed the Scottish Audit of Surgical Mortality (SASM) reports from 2001 (SASM 2003) and commented on them in the literature review. - The nature of data fed back to individual hospitals and in case assessments highlights that SASM is strong on providing technical feedback and on reporting the proximal causes of error but provides relatively little in the way of human factors information and therefore offered limited insight into non-technical skills in surgery. - Development and Evaluation of the NOTSS Behaviour Rating System 13 causes of this: (i) the forms used to collect data do not adequately capture human factors or non-technical contributions to incidents, and (ii) the coding framework used to analyse the incident reports does not adequately deal with non-technical skills. - A similar situation emerged in the analyses of anaesthetic adverse event reports for the ANTS project (Fletcher et al. - These conditions explain the current technical (e.g., what happened) bias in published audit reports in favour of non-technical (e.g., why it happened) causes of adverse events. - The SASM forms since 2007 include non-technical skills categories.. - The critical incident technique (CIT) is a type of cognitive interview (Crandall et al. - 2006, Flanagan 1954, Hoffmann et al. - CITs were conducted with 27 consultant surgeons in order to identify non-technical skills used by surgeons in the intra-operative environment. - By focusing on a specific memorable incident, the interviews provided insight into the surgeon’s use of information, strategies, meta-cognition, resources and interpersonal skills during an operative case (Yule et al. - see also Fletcher et al. - After the surgeon described the case, the interviewer recounted the sequence of events back to the surgeon and asked for clarification and more explanation of the course of events.. - This second sweep of the case allowed for more detail to be gleaned. - The case was then discussed for a third time with the addition of cognitive cues which recreate aspects of the case to elicit deeper-held tacit knowledge about the non- technical skills that were or were not being used. - Examples of the cognitive cues used include: ‘what cues were you using to help understand the situation’ and. - ‘how did you re-establish goals?’ The interview questions were developed by a multidisciplinary group, based on work in other domains including anaesthesia and piloted with three consultant surgeons. - One of the participants was female. - A variety of cases were discussed in the interviews which lasted around one hour each, including emergencies with duodenal ulcers, difficulties in hip and knee replacements, problems in transplant operations and difficulties with cardiac bypass. - Coders were asked to identify when non-technical skills were discussed in the interview and to interpret those specific skills
Xem thử không khả dụng, vui lòng xem tại trang nguồn hoặc xem
Tóm tắt